The British Journal of Health Psychology has posted a misleading review that has no pretense of a balanced evaluation of whether psychological interventions slow progression and increase survival time.

The American Cancer Society (ACS) has already warned cancer patients and their families that psychotherapy and support groups DO NOT improve prospects for survival of cancer. This review does not acknowledge this, and its conclusions outright contradict the ACS evaluation.

Note: This blog post contains a rich set of hyperlinks, some of them to material on my secondary blog Quick Thoughts. The posts at the secondary blog allow access to these materials without making this blog post overwhelming in length and detail. There is some redundancy, because of my assumption that many people will not be clicking on all of the links.

Feedback on this strategy is welcomed.

The British Journal of Health Psychologyreview can be studied as an example of false authority being created by distorted citation, which you can learn about from a BMJ article here.

Supposedly supportive studies are cited, but there is no citing of peer reviewed articles identifying serious statistical and methodological flaws that prevent these studies from being accepted as positive evidence.

Important studies that produce negative findings are not cited, even when they are high quality.

Other studies are cited with a misrepresentation of their relevance.

This blog post deals with the faulty science of the review, providing access to evidence that was distorted and suppressed in the review.

The British Journal of Health Psychology article has considerable overlap with what was already published in Psycho-Oncology and JAMA. The two tables in the British Journal of Health Psychology and Psycho-Oncology articles are identical, including their similar glaring omissions. The Psycho-Oncology shares nine of the 10 citations of the JAMA article.

A subsequent blog post addresses the politics obtaining privileged access publishing with limited or no peer-review in in British Journal of Health Psychology, JAMA, and Psycho-Oncology, ostensibly peer reviewed journals. Such privileged access to peer review journals impedes the re-evaluation of the status of scientific hypotheses because it insulates proponents’ claims from contrary evidence and recycles claims that have already been called into question.

What a wonderful world it would be if, when confronted with a diagnosis of cancer, patients could mobilize their immune system and extend their survival time by merely eating the right foods, practicing yoga and relaxation exercises, and venting their emotions in support groups. The idea that patients can exert control over their cancer with such steps is deeply entrenched in psychosomatic medicine and the imagination of the lay public, and evidence to the contrary has been sometimes bitterly resisted. Of course, cancer patients can use psychological techniques to relieve stress, or go to support groups for emotional relief and validation for their experiences and thereby improve the quality, if not the quantity of life. But the prospect of being able to improve the quality of life has always paled by comparison to the promise of being able actually to extend it.

If there is credible evidence that persons diagnosed with cancer can extend their lives using psychological techniques, the techniques should be widely disseminated and freely available. However, with no such evidence that these interventions are effective, it would be a cruel hoax to claim otherwise.

The risk is that cancer patients facing difficult choices about treatment and end-of-life will be drawn into bad decisions about alternative treatments because of false promises. Why should they undergo sickening and disfiguring treatment when all they need to do is learn to breathe, cope, and sleep better? Yet a more general risk is that the notion that cancer can be combated by psychological strategies and attitude will lead to cancer patients blaming themselves when their disease progresses. After all, they are told, cancer can be tamed by the power of the mind. So, if their cancer is not being tamed, they are simply not trying hard enough, thinking positive enough, displaying enough fighting spirit.

The grande dame of psycho-oncology, Jimmie Holland wrote that patients

feel guilty that they can’t control their illness… They look upon it as a weakness, partly as a result of the culture’s emphasis on psychological means of controlling cancer.

Russ Kunkel with wife Judith and son Jake.

From The Onion ISSUE 35•07 • Feb 24, 1999

An Onion story comes too close to the truth in satirizing the responsibility placed on persons with cancer by unrealistic claims the power of mind over the disease:

A story NOT from the Onion, but from the Clinical Psychiatry News demonstrates how professionals can use weak science to blame people with cancer and frighten them into seeking the illusion of mind control over their condition—or else face progression and possibly early death.

Many breast cancer patients attend support groups believing they are building their immune system and extending their lives. Support groups can prove ideal opportunities to receive support and obtain the satisfaction of giving support to others. But those cancer patients who only attend because of the illusion that they are getting a clinically significant effect on the immune system are victims of bad science.

There is a also a risk to the credibility of efforts to provide cancer patients in the families with the services they need. If we let the claims go unchallenged that psychosocial interventions can extend lives, maybe funding for cancer patients to psychosocial care will be temporarily increased.

However, ultimately such claims will be exposed as false. Those who clung to them will be seen as beating an unseemly retreat to a position ‘well, maybe we don’t extend life, but we increase the quality of life.’ Improving quality of life is in itself an important goal, but it pales by comparison to the previously promised extension of life.

The abstract of British Journal of Health Psychology article can be found here. The article itself is behind a paywall, but perhaps a PDF can be obtained by emailing a request to its author, David Spiegel dspiegel [at] stanford.edu

A table of studies Spiegel identifies as positive is shown below [Click on it to enlarge]. It appears in both the British Journal of Health Psychology and Psycho-Oncology articles.

The first study listed is the 1989 Lancet study, first-authored by Spiegel himself and has been cited over 1000 times. You might want to read the study here and form your own opinion before accessing my blog post here. Give Figure 1 a look and see if you notice something quite odd. In my blog post, I explain why this study did not produce convincing evidence that psychotherapy extended the lives of the women with metastatic breast cancer.

The 7 other studies Spiegel cites are discussed here, with some rich links to the studies and other discussions of them. Basically:

None of the studies classified as positive designated survival as the a priori primary outcome AND had equivalent medical treatment delivered to both the intervention and control groups.

No randomized trial that was designed with the goal of testing whether psychotherapy improved survival has ever obtained a positive effect.

These issues have been discussed previously in peer-reviewed reviews and commentaries, and you can find citations and links available here. Curiously, the British Journal of Health Psychology article makes no mention of any criticisms of Spiegel’s depiction of the studies.

A number of other well-designed studies failed to provide evidence that therapy and support groups can extend survival. The British Journal of Health Psychology article does not mention any of these, despite the article’s claim that it “reviews all published clinical trials addressing effects of psychotherapy on cancer survival.”

Another table [Click on it to enlarge] from the British Journal of Health Psychology and Psycho-Oncology articles lists studies that Spiegel says do not show that psycholotherapy and support groups extend cancer patients’ lives.

I agree with Spiegel that they do not provide positive evidence. But one of these studies is particularly obscure and of poor quality (Ilnyckyi), go ahead and try to find it on Pubmed or Google Scholar. Yet others (the two Kissane studies and one by Goodwin) are better designed and more accurately reported than the studies Spiegel cites as positive. You can find an extended discussion here.

Spiegel considers 8/15 studies positive in his box score assessment. But box scores are for evaluating baseball teams, not scientific studies, particularly when the studies have very different aims, designs—including sample sizes– and methodological quality. How many small flawed studies does it take to claim equivalence to one large, well designed study?

Protecting cancer patients from exaggerated claims about mind over cancer

Cancer patients frequently turn to the Internet for information about the best treatments for their disease. They can readily find false claims that conventional cancer treatments do more harm than good and that they should harness the power of the mind if they want to live longer. There are testimonials about conventional treatments failing were unconventional treatments exceed. There is often the insistence of having the backing of science. That sells.

Surfing the web, cancer patients may find a review in the open access Journal of Alternative Medicine Research that cites some of the same studies as the British Journal of Health Psychology article. It declares that the ‘creative novation behavior therapy’ of Ronald Grossarth-Maticek is the most effective psychotherapy for extending the lives of cancer patients.

Never mind that Grossarth-Maticek’s claims were investigated by an international team of experts, including David Spiegel, who dismissed the claims for this therapy as exaggerated, implausible, or outright fraudulent. The claims persist in a seemingly scientific journal citing other studies in scientific journals. We cannot expect that cancer patients will see through this or do a thorough systematic review of the literature before accepting such dazzling claims.

Other websites offer Laurence LeShan’s mobilization of the immune system with individual marathon therapy, workshops, and retreats with the promise “Our aim goes beyond “support”: it is to enhance and extend life.”

Working toward creating a richer, more fulfilling life appears to be far superior in survival time to that of traditional psychotherapies focusing on psychological problems and past causes. For people with cancer, this approach often increases their positive response to medical treatment by (theoretically) stimulating their self-healing abilities.

Still other sites offers the Simonton Method, which involves patient visualizing their cancer and treatment destroying the cancer through the mobilization of the immune system. Some of the therapeutic exercises involve imagining Pac-Men gobbling up and destroying the cancer cells. Hopefully they have now been updated to contemporary video games.

A couple of years ago, Elizabeth Simonton sent me a series of emails pleading with me to participate in a project that would explore her father’s Simonton Method. She stated that she had

interviewed such people as, Barrie Cassileth, David Spiegel, Carl Simonton, Jim Gordon, David Bresler, Bernie Siegel and many more. I am extremely interested in your point of view on the matter, as you have publicly expressed that you are skeptical of these ideas, and I am looking to get opinions such as yours to explore all of the facts behind the work….Please let me know if you would consider doing this interview, without it I feel the film would be lacking any sort of balance.

I refused to be interviewed. Let there be a lack of balance. Apparently, the film was never completed. But why couldn’t Ms Simonton apparently not identify other professionals to present the side she expected from me?

I think it is vitally important, that as much as we can influence what appears on the internet or in journals, we stick to evidence-based conclusions that there is NO evidence of mind triumphing over cancer, at least in terms of physical health outcomes. If British Journal of Health Psychology and Psycho-Oncology are going to create confusion with inadequately reviewed or unreviewed articles, then an authoritative body like the UK National Health Service should investigate the claims and issue a statement, just as the ACS has issued a statement.

So, NHS, please issue a statement to reduce any confusion on the part of cancer patients, their families, and their providers: No evidence that support groups or psychotherapy improve survival. Commission a review of the evidence, if you must. If it is free of the bias shown in the British Journal of Health Psychology and Psycho-Oncology articles, I am sure what the review would conclude.

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James C. Coyne, PhD is Professor of Health Psychology at University Medical Center, Groningen, the Netherlands where he teaches scientific writing and critical thinking. He is also Visiting Professor, Institute for Health, Health Care Policy & Aging Research, Rutgers, the State University of New Jersey.
Dr. Coyne is Emeritus Professor of Psychology in Psychiatry, where he was also Director of Behavioral Oncology, Abramson Cancer Center and Senior Fellow Leonard Davis Institute of Health Economics. He has served as External Scientific Advisor to a decade of European Commission funded community based programs to improve care for depression in the community. He has written over 350 articles and chapters, including systematic reviews of screening for distress and depression in medical settings and classic articles about stress and coping, couples research, and interpersonal aspects of depression. He has been designated by ISI Web of Science as one of the most impactful psychologists and psychiatrists in the world. His books include Screening for Depression in Clinical Settings: An Evidence-Based Review edited with Alex Mitchell (Oxford University Press; 2009). He also blogs and is a regular contributor to the blog Science Based Medicine and to the PLOS One Blog, Mind the Brain. He is known for giving lively, controversial lectures using scientific evidence to challenge assumptions about the optimal way of providing psychosocial care and care for depression to medical patients.
All views that Professor Coyne expresses are his own and do not necessarily reflect those of PLOS or other institutional affiliations.

9 comments

Thanks for this (took me a while to get through, but it was well worth it).

There seems to be a bit of a political project since the 90s promoting ‘stoicism’, a sense of personal control over life, and other such things amongst the British Establishment. I’d be surprised to see an authoritative body put out a clear statement undermining the belief that psychological approaches can be used to help prolong the life of cancer patients.

Who do you speak for Doctor ? How about spontaneous remission ? Why do those individuals just get ignored or where is the professional curiosity to find a common link. I know people disparage religion if claims are made that cancer was healed. I am not a religious person AND both of my parents were Christian Scientists and my father was a practitioner. I saw some amazing examples of healing when I was growing up even though I do not subscribe to any deistic form of worship my witnessing these transformations has taught me to be open!! In clinical medical research, what is the condition that defines effectiveness? PLACEBOS! Come on Doctor you can’t be serious to flatly deny metaphysics as entirely impotent in treating disease. Stay open and please don’t judge prior to investigation. Andrew Park LCSW